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After settling a three-year
Freedom of Information Act (FOIA) lawsuit, Kaiser Health News (KHN) last
month finally made public the results of multiple CMS audits of Medicare
Advantage plans — which showed the federal government intends to collect an
estimated $12 million for overpayments identified over a three-year period.
KHN said it filed the lawsuit against CMS in September 2019, after the agency
failed to respond to a FOIA request for the audits pertaining to care
delivered between 2011 and 2013.
Humana’s overpayments
surpassed $1,000 per patient
- Those years
represent the latest Risk Adjustment Data Validation (RADV) audits to be
completed, referring to contract-level audits conducted by CMS to verify
the accuracy of payments made to MA organizations and recover improper
payments.
- Through its
FOIA lawsuit, KHN exclusively
obtained summaries of 90 audits, which identified approximately
$12 million in net overpayments. Of the 71 audits that found overpayments,
23 involved an average per-patient overpayment that exceeded $1,000.
- The news report
said Humana Inc., one of the largest MA organizations, had overpayments
topping $1,000 per patient in 10 out of 11 audits.
- The audit
summaries showed that the overpayments stemmed largely from medical
records provided by plans not supporting diagnoses submitted for risk
adjustment, with unsupported conditions ranging from diabetes to heart
failure.
Experts argue compliance
practices have improved over time
- Industry
experts say the results obtained by KHN may not be representative of
insurer practices today, and that they highlight the overarching
question of whether the audit methodology that CMS may soon finalize
aligns with the current payment and bidding system that’s in place for
MA.
- Tricia
Beckmann, director with Faegre Drinker Consulting, points out that the
audits summarized in the report are very old at this point, and “the
market has changed in a lot of respects since then,” especially in terms
of new entrants.
- “There’s always
emphasis on the national plans since they have the most money at stake,
but the article does show that there are issues facing plans in terms of
compliance, and the potential implications of extrapolation are very
endemic and systemic to the market,” she observes.
- Sean Creighton,
managing director in the policy practice at Avalere Health, also
suggests viewing the older RADV results with a grain of salt. “The
program has grown, but I think it’s also fair to say that attention to
compliance has also grown over time.” CMS’s processes for conducting the
audits have improved, while plans and providers have gotten better at
preserving records in formats that can be more easily stored, accessed
and cross-referenced, points out Creighton.
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